Fast-tracking revisited: routine cardiac surgical patients need minimal intensive care

Multicenter observational study of patients who underwent cardiac surgery and were hospitalized in an intensive care unit (BraSIS 2): study protocol and statistical analysis plan

BACKGROUND

The perioperative management of patients undergoing cardiac surgery is highly complex and involves numerous factors. There is a strong association between cardiac surgery and perioperative complications. The Brazilian Surgical Identification Study (BraSIS 2) aims to assess the incidence of death and early postoperative complications, identify potential risk factors, and examine both the demographic characteristics of patients and the epidemiology of cardiovascular procedures.

METHODS AND ANALYSIS

BraSIS 2 is a multicenter observational study of patients who undergo cardiac surgery and who are admitted to the intensive care unit. The primary objective is to describe the risk factors and incidence of mortality or severe postoperative complications occurring within the first 3 postoperative days of cardiac surgery or until intensive care unit discharge (whichever event occurs first). Severe postoperative complications include acute myocardial infarction, acute respiratory distress syndrome, cardiorespiratory arrest with return of spontaneous circulation, Kidney Disease Improving Global Outcomes stage ≥ 2, a new surgical approach being conducted in an unscheduled event of urgency or emergency, renal replacement therapy, septic shock, severe bleeding, severe hemodynamic instability, stroke, unplanned reintubation, and unplanned use of a circulatory assistance device. The secondary outcomes include the evaluation of patient characteristics and descriptions of the performed surgeries and administered anesthesia. This study will also assess intraoperative and postoperative complications, as well as risk factors associated with postoperative complications and mortality. We expect to recruit 500 patients from at least 10 Brazilian intensive care units. Trial registration: NCT06154473; partial results.

Clinical Updates in Coronary Artery Disease: A Comprehensive Review

Despite significant goals achieved in diagnosis and treatment in recent decades, coronary artery disease (CAD) remains a high mortality entity and continues to pose substantial challenges to healthcare systems globally. After the latest guidelines, novel data have emerged and have not been yet considered for routine practice. The scope of this review is to go beyond the guidelines, providing insights into the most recent clinical updates in CAD, focusing on non-invasive diagnostic techniques, risk stratification, medical management and interventional therapies in the acute and stable scenarios. Highlighting and synthesizing the latest developments in these areas, this review aims to contribute to the understanding and management of CAD helping healthcare providers worldwide.

Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP)

The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.

A Quality Improvement Initiative to Decrease Inappropriate Intravenous Acetaminophen Use at an Academic Medical Center

Background: Following availability in the United States in 2011, intravenous acetaminophen (IV APAP) was added to many hospital formularies for multimodal pain control. In 2014, the price of IV APAP increased from $12/g to $33/g and became a top 10 medication expenditure at our institution. Objective: To promote appropriate IV APAP prescribing and reduce costs. Design, Setting, Participants: Quality improvement project at a 562-bed academic medical center involving all inpatient admissions from 2010 to 2017. Interventions: Using Plan-Do-Study-Act (PDSA) methodology, our Pharmacy & Therapeutics (P&T) committee aimed to reduce inappropriate use of IV APAP by refinement of restriction criteria, development of clinical decision support in the electronic medical record, education of clinical staff on appropriate use, and empowerment of hospital pharmacists to enforce restrictions. Measurements: Monthly IV APAP utilization and spending were assessed using statistical process control charts. Balancing measures included monthly usage of IV opioid, IV ketorolac, and oral ibuprofen. Results: Five PDSA cycles were conducted during the study period. Monthly spending on IV APAP decreased from the highest average of $56 038 per month to $5822 per month at study conclusion. Interventions resulted in an 80% annual cost savings, or an approximate savings of $600 000 per year. Usage of IV opioids, IV ketorolac, and oral ibuprofen showed no major changes during the study period. Conclusions: IV APAP can be restricted in a safe and cost effective manner without concomitant increase in IV opioid use.

Intensive care unit drug costs in the context of total hospital drug expenditures with suggestions for targeted cost containment efforts

PURPOSE

To assess costs of intensive care unit (ICU) related pharmacotherapy relative to hospital drug expenditures, and to identify potential targets for cost-effectiveness investigations. We offer the unique advantage of comparing ICU drug costs with previously published data a decade earlier to describe changes over time.

MATERIALS AND METHODS

Financial transactions for all ICU patients during fiscal years (FY) 2009-2012 were retrieved from the hospital's data repository. ICU drug costs were evaluated for each FY. ICU departments' charges were also retrieved and calculated as percentages of total ICU charges.

RESULTS

Albumin, prismasate (dialysate), voriconazole, factor VII and alteplase denoted the highest percentages of ICU drug costs. ICU drug costs contributed to an average of 31% (SD 1.0%) of the hospital's total drug costs. ICU drug costs per patient day increased by 5.8% yearly versus 7.8% yearly for non-ICU drugs. This rate was higher for ICU drugs costs at 12% a decade previous. Pharmacy charges contributed to 17.7% of the total ICU charges.

CONCLUSIONS

Growth rates of costs per year have declined but still drug expenditures in the ICU are consistently a significant driver in this resource intensive environment with a high impact on hospital drug expenditures.

Examining Health Care Costs: Opportunities to Provide Value in the Intensive Care Unit

As health care costs threaten the economic stability of American society, increasing pressures to focus on value-based health care have led to the development of protocols for fast-track cardiac surgery and for delirium management. Critical care services can be led by anesthesiologists with the goal of improving ICU outcomes and at the same time decreasing the rising cost of ICU medicine.

Fast-Track Cardiac Anesthesia: Choice of Anesthetic Agents and Techniques

Fast-track cardiac anesthesia (FTCA) incorporates early tracheal extubation, decreased length of intensive care unit (ICU) and hospital stay, and (ideally) should avoid or reduce complications to safely achieve cost-savings. A growing body of evidence from randomized trials has identified many anesthetic interventions that can improve outcome after cardiac surgery. These include new short-acting hypnotic, opioid, and neuromuscular blocking drugs. An effective FTCA program requires the appropriate selection of suitable patients, a lowdose opioid anesthetic technique, early tracheal extubation, a short stay in the ICU, and coordinated perioperative care. It is also dependent on the avoidance of postoperative complications such as excessive bleeding, myocardial ischemia, low cardiac output state, arrhythmias, sepsis, and renal failure. These complications will have a much greater adverse effect on hospital length of stay and healthcare costs. A number of clinical trials have identified interventions that can reduce some of these complications. The adoption of effective treatments into clinical practice should improve the effectiveness of FTCA.

Pulmonary Complications After Cardiac Surgery

Over the past two decades there has been a steady evolution in the practice of adult cardiac surgery with the introduction of “off-pump” surgery. However, respiratory complications remain a leading cause of postcardiac surgical morbidity and can prolong hospital stays and increase costs. The high incidence of pulmonary complications is in part due to the disruption of normal ventilatory function that is inherent to surgery in the thoracic region. Furthermore, patients undergoing such surgery often have underlying illnesses such as intrinsic lung disease (e.g., chronic obstructive pulmonary disease) and pulmonary dysfunction secondary to cardiac disease (e.g., congestive heart failure) that increase their susceptibility to postoperative respiratory problems. Given that many patients undergoing cardiac surgery are thus susceptiple to pulmonary complications, it is remarkable that more patients do not suffer from them during and after cardiac surgery. This is to a large degree because of advances in anesthetic, surgical and critical care that, for example, have reduced the physiological insults of surgery (e.g., better myocardial preservation techniques) and streamlined care in the immediate postoperative period (e.g., early extubation). Moreover, the development of minimally invasive surgery and nonbypass techniques are further evidence of the attempts at reducing the homeostatic disruptions of cardiac surgery. This review examines the available information on the incidences, consequences, and treatments of postcardiac surgery respiratory complications.

The SYNTAX score is correlated with long-term outcomes of coronary artery bypass grafting for complex coronary artery lesions

OBJECTIVES

We analysed retrospectively the long-term outcomes of conventional coronary artery bypass grafting (CABG) as employed routinely for complex coronary lesions by observing patients with low (0-22), intermediate (23-32) and high (≥33) SYNTAX scores. The purpose of this study was to evaluate the correlation between the SYNTAX score and long-term major adverse cardiac and cerebrovascular events (MACCEs) including all-cause death, stroke, myocardial infarction (MI) and repeat revascularization after CABG.

METHODS

The study enrolled 396 consecutive patients with stable and untreated left main and/or three-vessel disease, who had been referred to our heart team from 2000 through 2009. They all routinely underwent conventional CABG. The three groups (low score; n = 159, intermediate score; n = 150, high score; n = 87) were compared, looking at the primary endpoint of MACCE and its components. We also analysed the effects of diverse variables on long-term MACCEs after the operation.

RESULTS

The cumulative 10-year MACCE rates in patients with low, intermediate and high SYNTAX score were 25.3, 35.8 and 48.1%, respectively. The Kaplan-Meier cumulative event curves showed a significantly higher MACCE rate after CABG in patients with a higher SYNTAX score than in those with a lower score (log-rank P = 0.0012). This was mainly because of a significantly increased rate of repeat revascularization in the higher SYNTAX score group (log-rank P = 0.0032). The cumulative rate of repeat revascularization at 10 years in patients having low, intermediate and high SYNTAX score were, respectively, 4.6, 15.7 and 16.8%. The cumulative rates of the combined outcomes of death/stroke/MI at 10 years did not show statistical differences between the three groups (22.3% with low, 25.0% with intermediate and 38.4% with high score, log-rank P = 0.063). In the multivariable analysis, the SYNTAX score [hazard ratio (HR) 1.03, P = 0.0043] and logistic EuroSCORE II (HR 1.34, P = 0.0012) were found to be significant predictors of long-term MACCEs.

CONCLUSIONS

The SYNTAX score is correlated with long-term outcomes, in terms of MACCEs, after conventional CABG for complex coronary lesions and is prognostic of long-term outcomes of CABG for patients with complex lesions.

A specialized post anaesthetic care unit improves fast-track management in cardiac surgery: a prospective randomized trial

Introduction

Fast-track treatment in cardiac surgery has become the global standard of care. We compared the efficacy and safety of a specialised post-anaesthetic care unit (PACU) to a conventional intensive care unit (ICU) in achieving defined fast-track end points in adult patients after elective cardiac surgery.

Methods

In a prospective, single-blinded, randomized study, 200 adult patients undergoing elective cardiac surgery (coronary artery bypass graft (CABG), valve surgery or combined CABG and valve surgery), were selected to receive their postoperative treatment either in the ICU (n = 100), or in the PACU (n = 100). Patients who, at the time of surgery, were in cardiogenic shock, required renal dialysis, or had an additive EuroSCORE of more than 10 were excluded from the study. The primary end points were: time to extubation (ET), and length of stay in the PACU or ICU (PACU/ICU LOS respectively). Secondary end points analysed were the incidences of: surgical re-exploration, development of haemothorax, new-onset cardiac arrhythmia, low cardiac output syndrome, need for cardiopulmonary resuscitation, stroke, acute renal failure, and death.

Results

Median time to extubation was 90 [50; 140] min in the PACU vs. 478 [305; 643] min in the ICU group (P <0.001). Median length of stay in the PACU was 3.3 [2.7; 4.0] hours vs. 17.9 [10.3; 24.9] hours in the ICU (P <0.001). Of the adverse events examined, only the incidence of new-onset cardiac arrhythmia (25 in PACU vs. 41 in ICU, P = 0.02) was statistically different between groups.

Conclusions

Treatment in a specialised PACU rather than an ICU, after elective cardiac surgery leads to earlier extubation and quicker discharge to a step-down unit, without compromising patient safety.

Trial registration

ISRCTN71768341. Registered 11 March 2014.

Long-term outcomes and risk analyses of coronary bypass for left main disease

BACKGROUND

We retrospectively analyzed the long-term outcomes and risk predictors of conventional coronary artery bypass grafting routinely employed for patients with left main disease.

METHODS

From January 2000 through December 2009, conventional coronary artery bypass grafting was routinely employed in 193 consecutive patients with left main disease. Long-term analyses were performed, looking at the primary endpoint of major adverse cardiac and cerebrovascular events which included all-cause death, stroke, myocardial infarction, and repeat revascularization. We also analyzed the effects of variables on major adverse cardiac and cerebrovascular events at 9 years after the operation.

RESULTS

The overall 9-year rates of combined outcomes (death, stroke, myocardial infarction), repeat revascularization, and major adverse cardiac and cerebrovascular events were 20.2%, 8.9%, 27.7%, respectively. The SYNTAX score was demonstrated to be the only significant predictor of combined outcomes at 9 years (hazard ratio 1.04, p = 0.033), repeat revascularization at 9 years (hazard ratio 1.11, p = 0.0030), and major adverse cardiac and cerebrovascular events at 9 years (hazard ratio 1.07, p = 0.0003).

CONCLUSIONS

With our routine strategy of conventional coronary artery bypass for left main disease, patients revealed excellent long-term outcomes in terms of major adverse cardiac and cerebrovascular events. These results provide a suitable benchmark against which long-term outcomes of percutaneous coronary intervention for left main disease can be compared. The SYNTAX score, which was introduced to determine treatment for complex coronary disease, is indicative of long-term outcomes after coronary artery bypass for left main disease.

Optimal occupancy in the ICU: a literature review

INTRODUCTION

In intensive care, occupancy is a commonly used measure. There is inconsistency however in its measurement and optimal occupancy targets need to be defined. The objectives of this literature review were to explore how occupancy is measured, reported, and interpreted and investigate optimal occupancy levels for ICUs.

METHOD

A literature search was performed using the Medline, Embase and CINAHL databases and citation tracking identified additional relevant articles. Articles published since 1997, written in English and focused on the adult ICU setting were included. As a result, 16 articles were selected for this review.

RESULTS

Although it was apparent there was no commonly accepted or used method for calculating ICU occupancy, methods described as more accurate enumerate actual patient hours in the ICU, use operational (and preferably fully staffed) beds as the denominator, and are calculated daily. Issues pertaining to the utility, interpretation, and reporting of ICU occupancy measures were identified and there were indications that optimal ICU occupancy rates were around 70-75%. It was evident however that setting a uniform target figure for all ICUs would be problematic as there are a range of factors both at the unit and the hospital level that impact occupancy figures and optimal occupancy levels.

IMPLICATIONS

This literature review informed the recommendation of a proposed method for calculating ICU occupancy which provides a realistic measure of occupied bed hours as a percentage of available beds. Despite the importance of gaining an understanding of ICU occupancy at the local and broader health system levels, there are a number of unknown factors that require further research. Appropriate occupancy targets, impact of unavailable beds, and the intrinsic and extrinsic factors on occupancy measurement are a few examples of where more information is required to adequately inform ICU monitoring, planning and evaluation activities.

Long-term outcomes and comparison after conventional coronary artery bypass grafting for left main disease between patients classified as percutaneous coronary intervention recommendation classes II and III

OBJECTIVES

We retrospectively analysed long-term outcomes after conventional coronary artery bypass grafting (CABG) between patients having left main (LM) disease who should have been assigned class II and those assigned class III recommendation for percutaneous coronary intervention (PCI) according to the 2010 European Society of Cardiology and the European Association for Cardio-Thoracic Surgery guidelines.

METHODS

From January 2000 to December 2009, conventional CABG was routinely employed in 180 consecutive patients with previously untreated and stable LM lesion. A comparison between two groups (CABG for PCI class II and CABG for PCI class III) was performed, looking at the primary endpoint of major adverse cardiac and cerebrovascular events (MACCE), including all-cause death, stroke [cerebral vascular accident (CVA)], myocardial infarction (MI) and repeat revascularization. We also analysed the effects of variables on MACCE at 8 years after the operation.

RESULTS

The overall 8-year MACCE rates were significantly lower in the CABG for PCI class II group than in the CABG for PCI class III group (9.7% class II vs 31.1% class III; P = 0.0005). This was largely because of an increased rate of repeat revascularization (1.2% class II vs 13.8% class III; P = 0.0029). The cumulative rate of the combined outcomes of all death/CVA/MI was significantly lower in the CABG for PCI class II group (8.5% class II vs 19.2% class III; P = 0.048); there was no observed difference between the groups for all-cause death, CVA and MI. The SYNTAX score was demonstrated to be the only significant predictor of combined outcomes (Death/CVA/MI) at 8 years [odds ratio (OR) 1.05, P = 0.023], repeat revascularization at 8 years (OR 1.11, P = 0.0013) and MACCE at 8 years (OR 1.07, P < 0.0001).

CONCLUSIONS

In our routine strategy of conventional CABG for LM disease, patients believed to be PCI candidates for LM disease have significantly better long-term outcomes as characterized by combined outcomes (Death/CVA/MI), repeat revascularization and MACCE. These results provide a suitable benchmark against which long-term outcomes of PCI for LM disease can be compared. The SYNTAX score, which was introduced to determine treatment for complex coronary disease, is indicative of long-term outcomes after CABG for LM disease.

Risk factor analysis for fast track protocol failure

BACKGROUND

The introduction of fast-track treatment procedures following cardiac surgery has significantly shortened hospitalisation times in intensive care units (ICU). Readmission to intensive care units is generally considered a negative quality criterion. The aim of this retrospective study is to statistically analyse risk factors and predictors for re-admission to the ICU after a fast-track patient management program.

METHODS

229 operated patients (67 ± 11 years, 75% male, BMI 27 ± 3, 6/2010-5/2011) with use of extracorporeal circulation (70 ± 31 min aortic crossclamping, CABG 62%) were selected for a preoperative fast-track procedure (transfer on the day of surgery to an intermediate care (IMC) unit, stable circulatory conditions, extubated). A uni- and multivariate analysis were performed to identify independent predictors for re-admission to the ICU.

RESULTS

Over the 11-month study period, 36% of all preoperatively declared fast-track patients could not be transferred to an IMC unit on the day of surgery (n = 77) or had to be readmitted to the ICU after the first postoperative day (n = 4). Readmission or ICU stay signifies a dramatic worsening of the patient outcome (mortality 0/10%, mean hospital stay 10.3 ± 2.5/16.5 ± 16.3, mean transfusion rate 1.4 ± 1,7/5.3 ± 9.1). Predicators for failure of the fast-track procedure are a preoperative ASA class > 3, NYHA class > III and an operation time >267 min ± 74. The significant risk factors for a major postoperative event (= low cardiac output and/or mortality and/or renal failure and/or re-thoracotomy and/or septic shock and/or wound healing disturbances and/or stroke) are a poor EF (OR 2.7 CI 95% 0.98-7.6) and the described ICU readmission (OR 0.14 CI95% 0.05-0.36).

CONCLUSION

Re-admission to the ICU or failure to transfer patients to the IMC is associated with a high loss of patient outcome. The ASA > 3, NYHA class > 3 and operation time >267 minutes are independent predictors of fast track protocol failure.

A case-control study of readmission to the intensive care unit after cardiac surgery

BACKGROUND

The aim of this study was to identify predictors of repeated admission to the intensive care unit (ICU) of patients who underwent cardiac surgery procedures.

MATERIAL/METHODS

This retrospective study analyzed 169 patients who underwent isolated coronary artery bypass grafting (CABG) between January 2009 and December 2010. The case group contained 54 patients who were readmitted to the ICU during the same hospitalization and the control group comprised 115 randomly selected patients.

RESULTS

Logistic regression analysis revealed that independent predictors for readmission to the ICU after CABG were: older age of patients (odds ratio [OR] 1.04; CI 1.004-1.08); body mass index (BMI)>30 kg/m2 (OR 2.55; CI 1.31-4.97); EuroSCORE II>3.9% (OR 3.56; CI 1.59-7.98); non-elective surgery (OR 2.85; CI 1.37-5.95); duration of operation>4 h (OR 3.44; CI 1.54-7.69); bypass time>103 min (OR 2.5; CI 1.37-4.57); mechanical ventilation>530 min (OR 3.98; CI 1.82-8.7); and postoperative central nervous system (CNS) disorders (OR 3.95; CI 1.44-10.85). The hospital mortality of patients who were readmitted to the ICU was significantly higher compared to the patients who did not require readmission (17% vs. 3.8%, p=0.025).

CONCLUSIONS

Identification of patients at risk of ICU readmission should focus on older patients, those who have higher BMI, who underwent non-elective surgery, whose operation time was more than 4 hours, and who have postoperative CNS disorders. Careful optimization of these high-risk patients and caution before discharging them from the ICU may help reduce the rate of ICU readmission, mortality, length of stay, and cost.

Costs of critical care medicine

The main drivers of critical care medicine (CCM) costs are the numbers and use of intensive care unit (ICU) beds. The Russell equation, an indirect costing methodology, is most commonly used to estimate national CCM costs. Calculating national CCM costs in a standardized manner remains challenging because there is no universal approach to defining the types of hospitals, ICU beds, days, and billing codes to be included in the overall cost. Although numerous CCM cost-containment strategies have been proposed or implemented, CCM cost reduction remains elusive, and measuring cost remains challenging,given the complexities involved in assessing costs.

A Clinical and Economic Evaluation of Fast-Track Recovery after Cardiac Surgery

<p><b>Background:</b> In the last 5 decades, the care of cardiac surgical patients has improved with the aid of strategies aimed at facilitating patient recovery. One of the innovations in this context is "fast-tracking" or "rapid recovery." This process refers to all interventions that aim to shorten a patient's stay in the intensive care unit (ICU) through accelerating the patient's transfer to a step-down or telemetry unit and to the general ward.</p><p><b>Methods:</b> Patients were allocated to 2 groups. The fast-track group (n = 84) went through an independent theatre recovery unit (TRU). The patients were then transferred on the same day to an intermediate care unit and transferred on the following day to the ward. The intensive care group (52 patients) went to the ICU for at least 1 day, after which they were transferred to the ward.</p><p><b>Results and Discussion:</b> The fast-track pathway significantly reduced the length of stay (LOS) in an intensive care facility (<i>P</i> < .001). The duration of intubation was reduced from a median of 4.08 hours (range, 1.17-13.17 hours) in the intensive care group to 2.75 hours (range, 0.25-18.57 hours) in the fast-track group (<i>P</i> < .001). However, the median values for total hospital LOS, incidences of complications, reintubation, and readmission were similar for the 2 groups. The incidence of failure in the fast-track group was 10%. The mean (SD) cost of the perioperative care was �4182 � �2284 ($6683 � 3650) for the fast-track patients, compared with �4553 � �1355 ($7277 � $2165) for the intensive care group.</p><p><b>Conclusion:</b> Fast-track recovery after cardiac surgery decreases the intensive care LOS and the total duration of intubation. It is a cost-effective strategy compared with conventional recovery protocols; however, it does not reduce the total hospital LOS or the incidence of complications.</p>

What happens after discharge? An analysis of long-term survival in cardiac surgical patients requiring prolonged intensive care

BACKGROUND

Cardiac surgical patients with postoperative complications frequently require prolonged intensive care yet survive to hospital discharge.

METHODS

From January 1, 2002 to December 31, 2007, 11,541 consecutive patients underwent cardiac operations at a single academic institution. Of these, 11,084 (95.9%) survived to hospital discharge and comprised the study sample. Patients were retrospectively categorized into four groups according to intensive care unit (ICU) length of stay (LOS): <3 days, three to seven days, 7 to 14 days, and >14 days. Survival at 12 months was determined using the Social Security Death Index. Kaplan-Meier (KM) survival curves and Cox proportional hazards regression modeling (hazard ratio, HR) were used to analyze group differences in survival.

RESULTS

One-year survival among the four groups according to ICU LOS was: <3 days, 97.0% (8407/8666); three to seven days, 91.2% (1481/1625); 7 to 14 days, 87.9% (356/405); and >14 days, 68.3% (265/388) (p < 0.001). Using multivariable regression analysis, adjusted overall mortality was significantly greater in patients with ICU LOS of three to seven days (HR = 1.51), 7 to 14 days (HR = 1.40), and >14 days (HR = 1.90) compared to patients with ICU LOS <3 days. Mortality among patients who survived more than six months postsurgery was significantly greater in patients with ICU LOS of three to seven days (HR = 1.37), 7 to 14 days (HR = 1.34), and >14 days (HR = 1.63).

CONCLUSIONS

Although cardiac surgery patients with major postoperative complications frequently survive to hospital discharge, survival after discharge is significantly reduced in patients requiring prolonged ICU care. Reduced survival in patients with a high risk of complications and anticipated long ICU stays should be considered when discussing surgical versus nonsurgical options.

Outcome after valve surgery in octogenarians and efficacy of early mobilization with early cardiac rehabilitation

PURPOSE

This study aimed to compare postoperative complications and the surgical outcome in patients aged <80 years versus octogenarian patients. Another aim was to evaluate the safety and efficacy of early mobilization with early cardiac rehabilitation in octogenarians.

METHODS

A retrospective analysis was performed in 138 consecutive patients (group Y comprised 118 patients <80 years, and group O comprised 20 octogenarians) who had undergone valve surgery at the authors' institution between July 2007 and December 2009. Furthermore, the efficacy of early mobilization with early cardiac rehabilitation and long-term results were analyzed in 40 consecutive octogenarian patients undergoing valve surgery from 2000. The late survival follow-up was 100% complete.

RESULTS

Redo cardiac operations were more frequent (O group 15.0% vs. Y group 3.4%, P = 0.011), and the preoperative EuroSCORE was significantly higher in group O than in group Y (group O 16.4 ± 18.3 vs. group Y 7.5 ± 9.1, P = 0.001). The incidence of delirium/confusion and worsening of renal function after surgery was higher in group O. The hospital mortality was 1.7% in group Y and no hospital death in group O (P > 0.99). Early mobilization with early cardiac rehabilitation significantly reduced the incidence of postoperative delirium/confusion and increased the number of patients who could return directly home. The actuarial 5-year survival rate was 77.7% for octogenarians.

CONCLUSION

Although there were more high-risk patients among the octogenarians, valve surgery was a safe, low-risk procedure with excellent long-term results. Early mobilization with early cardiac rehabilitation was significantly effective and safe for postoperative recovery in octogenarians after cardiac valve surgery.

Lessons from the SYNTAX trial

Despite the fact that CABG is the standard of care for patients with multivessel coronary arteries and/or left main stem stenosis, PCI has become a rival to CABG in patients with multivessel coronary artery disease or left main disease. However, the need for repeat revascularization, in-stent stenosis and thrombosis remain the achilis heal of PCI. SYNTAX trial randomized patients with left main disease and/or three-vessel disease to PCI with TAXus stent or CABG with the concept that PCI is not inferior to CABG. At 1 and 2 years follow up, MACCE was significantly increased in PCI patients mainly attributed to increased rate of repeat revascularization; however, stroke was significantly more with CABG. The composite safety endpoint of death/stroke/MI was comparable between the 2 groups. Therefore the criterion for non-inferiority was not met. What we learn from SYNTAX is that multi disciplinary team approach should be the standard of care when recommending treatment in more complex coronary artery disease. SYNTAX makes interventionists and surgeons come together, it may set the benchmark for MVD revascularization. PCI and CABG should be considered complementary rather than competitive revascularization strategies. There is no substitute for sound clinical judgment that takes into account the patient's overall clinical profile, functionality, co-morbidities, as well as the patient's coronary anatomy. The SYNTAX Score should be utilized to decide on treatment of patients with LM/MVD. Patients with low and intermediate score can be treated with PCI or CABG with equal results. Those with high score do better with CABG. SYNTAX trial showed that 66% of patients with 3VD or LMD are still best treated with CABG. In the remaining 1/3 of patients with low syntax score, PCI may be considered as an alternative to surgery. Finally, medical treatment should be optimized in patients going for CABG.

Can the costs of critical care be controlled?

PURPOSE OF REVIEW

Critical care medicine (CCM) is expensive. CCM costs have continued to rise since they were first calculated in the 1970s. By 2005, CCM costs in the US were estimated to be $81.7 billion accounting for 13.4% of hospital costs, 4.1% of the national health expenditures and 0.66% of the gross domestic product.

RECENT FINDINGS

This review first addresses the methodology and inherent limitations of calculating global CCM costs using the Russell equation and the challenges of defining critical care in the US when universal definitions of intensive care unit (ICU) bed types do not exist. Studies and concepts recently put forth to control CCM costs are then discussed. These include rationing ICU care, caring for patients in non-ICU locations, regionalizing care, changing the ICU workforce, imposing care protocols and bundles, and adjusting long-term ICU traditions. Many of these programs have benefits but may also have unintended expenses. Even documenting ICU costs themselves may be quite challenging as costs are frequently shifted between the ICU and its supporting clinical and hospital services.

SUMMARY

Cost containment is difficult to attain in critical care as the programs proposed to achieve cost control may be so pricey, that potential cost savings are offset. Some CCM cost saving methodologies may benefit patient care, whereas others may be detrimental to society. CCM cost containment may prove as illusory in the future as it has been in the past.

Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs

OBJECTIVES

To analyze the evolving role, patterns of use, and costs of critical care medicine in the United States from 2000 to 2005.

DESIGN

Retrospective study of data from the Hospital Cost Report Information System (Centers for Medicare and Medicaid Services, Baltimore, Maryland).

SETTING

Nonfederal, acute care hospitals with critical care medicine beds in the United States.

SUBJECTS

None.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We analyzed hospital and critical care medicine beds, bed types, days, occupancy rates, payer mix (Medicare and Medicaid), and costs. Critical care medicine costs were compared with national cost indexes. Between 2000 and 2005, the total number of U.S. hospitals with critical care medicine beds decreased by 12.2% (from 3,586 to 3,150). Although the number of hospital beds decreased by 4.2% (from 655,785 to 628,409), both hospital days and occupancy rates increased by 5.1% (from 145.1 to 152.5 million) and 13.7% (from 59% to 67%), respectively. Critical care medicine beds increased by 6.5% (from 88,252 to 93,955), days by 10.6% (from 21.0 to 23.2 million), and occupancy rates by 4.5% (from 65% to 68%). The majority (90%) of critical care medicine beds were classified as intensive care, premature/neonatal, and coronary care unit beds. The percentage of critical care medicine days used by Medicare decreased by 3.8% (from 37.9% to 36.5%) compared with an increase of 15.5% (from 14.5% to 16.8%) by Medicaid. From 2000 to 2005, critical care medicine costs per day increased by 30.4% (from $2698 to $3518). Although annual critical care medicine costs increased by 44.2% (from $56.6 to $81.7 billion), the proportion of hospital costs and national health expenditures allocated to critical care medicine decreased by 1.6% and 1.8%, respectively. However, the proportion of the gross domestic product used by critical care medicine increased by 13.7%. In 2005, critical care medicine costs represented 13.4% of hospital costs, 4.1% of national health expenditures, and 0.66% of the gross domestic product.

CONCLUSIONS

Critical care medicine continues to grow in a shrinking U.S. hospital system. The critical care medicine payer mix is evolving, with Medicaid increasing in its percentage of critical care medicine use. Critical care medicine is more cost controlled than other healthcare indexes, but is still using an increasing percentage of the gross domestic product. Our updated and comprehensive critical care medicine use and cost analysis provides a contemporary benchmark for the strategic planning of critical care medicine services within the U.S. healthcare system.

[Leipzig fast-track protocol for cardio-anesthesia. Effective, safe and economical]

BACKGROUND

In November 2005 a complex, multimodal anesthesia fast-track protocol (FTP) was introduced for elective cardiac surgery patients in the Cardiac Center of the University of Leipzig which included changing from an opioid regime to remifentanil and postoperative treatment in a special post-anesthesia recovery and care unit. The goal was to speed up recovery times while maintaining safety and improving costs.

METHOD

A total of 421 patients who underwent the FTP and were treated in the special recovery room were analyzed retrospectively. These patients were compared with patients who had been treated by a standard protocol (SP) prior to instituting the FTP. Primary outcomes were time to extubation, length of stay in the intensive care unit (ICU) and treatment costs.

RESULTS

The times to extubation were significantly shorter in the FTP group with 75 min (range 45-110 min) compared to 900 min (range 600-1140 min) in the SP group. Intensive care unit stay and hospital length of stay were also significantly shorter in the FTP group (p<0.01). The reduction of treatment costs of intensive care for FTP patients was 53.5% corresponding to savings of EUR 738 per patient in the FTP group compared with the SP group.

CONCLUSIONS

The Leipzig fast-track protocol for cardio-anesthesia including the central elements of switching opiate therapy to remifentanil and switching patient recovery to a special post-anesthesia recovery and care unit, shortened therapy times, is safe and economically effective.

Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease

BACKGROUND

Percutaneous coronary intervention (PCI) involving drug-eluting stents is increasingly used to treat complex coronary artery disease, although coronary-artery bypass grafting (CABG) has been the treatment of choice historically. Our trial compared PCI and CABG for treating patients with previously untreated three-vessel or left main coronary artery disease (or both).

METHODS

We randomly assigned 1800 patients with three-vessel or left main coronary artery disease to undergo CABG or PCI (in a 1:1 ratio). For all these patients, the local cardiac surgeon and interventional cardiologist determined that equivalent anatomical revascularization could be achieved with either treatment. A noninferiority comparison of the two groups was performed for the primary end point--a major adverse cardiac or cerebrovascular event (i.e., death from any cause, stroke, myocardial infarction, or repeat revascularization) during the 12-month period after randomization. Patients for whom only one of the two treatment options would be beneficial, because of anatomical features or clinical conditions, were entered into a parallel, nested CABG or PCI registry.

RESULTS

Most of the preoperative characteristics were similar in the two groups. Rates of major adverse cardiac or cerebrovascular events at 12 months were significantly higher in the PCI group (17.8%, vs. 12.4% for CABG; P=0.002), in large part because of an increased rate of repeat revascularization (13.5% vs. 5.9%, P<0.001); as a result, the criterion for noninferiority was not met. At 12 months, the rates of death and myocardial infarction were similar between the two groups; stroke was significantly more likely to occur with CABG (2.2%, vs. 0.6% with PCI; P=0.003).

CONCLUSIONS

CABG remains the standard of care for patients with three-vessel or left main coronary artery disease, since the use of CABG, as compared with PCI, resulted in lower rates of the combined end point of major adverse cardiac or cerebrovascular events at 1 year. (ClinicalTrials.gov number, NCT00114972.)

Optimizing early extubation after coronary surgery

Early extubation after isolated coronary artery bypass surgery was assessed retrospectively in 545 of 779 patients treated by the same surgical team over one year. All underwent extubation within 10 hr of arrival at the cardiothoracic intensive care unit: 343 in < 6 hr and 202 in 6-10 hr. Operative mortality was 2.2%. Group comparisons revealed that patients who had earlier extubation were younger (61 vs. 66 years; p < 0.001), more likely to be male (72.5% vs. 61.3%; p < 0.05), with a shorter aortic crossclamp time (49.2 +/- 15.0 vs. 53.3 +/- 14.0 min; p < 0.05), cardiopulmonary bypass time (65 +/- 18.4 vs. 72.2 +/- 19.2 min; p < 0.05), intensive care unit stay (18.8 +/- 5.6 vs. 22.4 +/- 3.2 hr; p < 0.05) and postoperative hospital stay (5.2 +/- 2.2 vs. 6.0 +/- 2.4 days; p = 0.01). Extubation < 6 hr after cardiopulmonary bypass may accelerate recovery. The finding of no significant differences in clinical parameters between the groups suggests that efforts to further reduce the time to extubation might be worthwhile.

Fast-track cardiac surgery: application in an Australian setting

In response to the current state of healthcare in Australia, our unit has employed a fast-track policy for low-risk cardiac surgery patients since January 2000. This study was designed to examine the safety and efficacy of this policy. From July 2001 to June 2004, 342 (23%) of 1,488 patients undergoing cardiac surgery were identified preoperatively as suitable for fast-track recovery. There was a significantly shorter median time to extubation (4 hr vs 9 hr), reduced intensive care unit stay (8 hr vs 26 hr), and a lower rate of readmission to the intensive care unit (0.6% vs 4.2%) for those fast tracked compared to the other patients. The fast-track group had a lower incidence of complications and significantly decreased median length of hospital stay (5 vs 7 days). We concluded that this policy accurately identifies the low-risk cardiac surgery patients suitable for less intensive postoperative recovery.

Early oral analgesia after fast-track cardiac anesthesia

PURPOSE

Oral analgesia after "fast-track" cardiac anesthesia has not been explored. The aim of this study was to compare two oral oxycodone analgesic regimens.

METHODS

One hundred-twenty patients scheduled for coronary artery bypass grafting were randomly assigned postoperatively to receive immediate-release oxycodone 5 mg and acetaminophen 325 mg (Percocet-5) (group I) per os four times daily, or controlled-release oxycodone 10 mg (OxyContin) (group II) per os every 12 hr and placebo twice daily. Acetaminophen 500 mg per os was used as first-line rescue medication, and immediate-release oxycodone (syrup form) 5 mg per os as second-line rescue medication. Pain intensity was assessed with a visual analogue scale on the first postoperative day, the morning after extubation, and thereafter four times daily for four days. Use of rescue medication and adverse events were recorded.

RESULTS

Baseline demographic and operation-related characteristics were similar in both groups. While pain control was good in both groups, the immediate-release group experienced less pain on all postoperative days (P = 0.003), required significantly less rescue medication, and had fewer adverse effects such as somnolence and nausea.

CONCLUSION

Peroral oxycodone is effective for early pain control after fast-track cardiac anesthesia. Immediate-release oxycodone/ acetaminophen appears to provide better analgesia and fewer side effects compared to controlled-release oxycodone.

Mechanical Ventilation for Cardiac Support

Postoperative lung injury is a common, although decreasing, complication of cardiac surgery. This article discusses various means to prevent and minimize postoperative lung injury. These include lung-protective strategies, pharmacologic strategies, and mechanical ventilation.

Fast-track failure after cardiac surgery: Development of a prediction model*

OBJECTIVE

Risk factors for unsuccessful fast-tracking of cardiac surgery patients have not been collectively defined in the literature. The aim of this study was to determine risk factors for fast-track failure and incorporate them into a predictive fast-track failure score.

DESIGN

Prospective observational study.

SETTING

Cardiothoracic Department of St Mary's Hospital, London.

PATIENTS

Data were collected from April 2003 to April 2005 including 1,084 patients undergoing heart surgery who were admitted into the fast-track unit.

INTERVENTIONS

Multifactorial logistic regression was used to develop a propensity score for estimating the likelihood of fast-track failure.

MEASUREMENTS AND MAIN RESULTS

One hundred and sixty-nine patients failed fast-track management (15.6%). Independent predictors for fast-track failure were impaired left ventricular function with or without recent acute coronary syndrome (odds ratios 2.89 and 1.65 respectively), re-do operation (one, two, or more vs. none, odds ratio 1.75, 7.98), extracardiac arteriopathy (odds ratio 2.63), preoperative intra-aortic balloon pump (odds ratio 3.09), raised serum creatinine in micromol/L (120-150, >150 vs. <120, odds ratio 1.57, 11.24), and nonelective (odds ratio 3.43) and complex surgery (odds ratio 2.70). Model validation showed very good discrimination (area under the curve = 0.815) and calibration (ĉ statistic = 8.527, p = .129).

CONCLUSIONS

The fast-track failure score incorporates several preoperative factors and has been successfully internally validated; after undergoing external validation and possible recalibration it may be used as a tool to facilitate planning and flow of cardiac surgery patients, based on the predicted probability of failure. Application of this score may limit fast-track failure rates and help to reduce morbidity and cost.

Gender Differences for Rapid After Bypass Back Into Telemetry Tract Following Cardiac Surgery

The Rapid After Bypass Back Into Telemetry program is based on a simple clinical algorithm to predict same-day transfer of patients to the cardiac telemetry unit following cardiac surgery. This program proved to be an excellent predictor for decreased postoperative complications, shorter intensive care unit and hospital stay, and lower costs. We believe that any candidate for cardiac surgery should be screened for eligibility to participate in the program with special focus on female patients to further improve their outcomes.

The SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) study: design, rationale, and run-in phase

BACKGROUND

Changes in the treatment of coronary artery disease both surgically and percutaneously have rendered the major randomized trials historical. Furthermore, the restrictive criteria of previous trials excluded most patients treated in daily practice. Although coronary surgery is still considered the current, evidence-based, gold-standard treatment of left main (LM) and 3-vessel coronary disease, the added benefit of drug-eluting stents has further expanded the use of percutaneous coronary intervention (PCI) beyond less complex populations in daily practice.

STUDY DESIGN

The 1500-patient, prospective, multicenter, multinational (European and North American), randomized SYNTAX study with nested registries will enroll "all-comers." Consecutive patients with de novo 3-vessel disease (3VD) and/or LM disease will be screened for eligibility by the Heart Team (composed of an interventionalist, a cardiac surgeon, and the study coordinator) at each site and then allocated to either (1) the randomized cohort, if comparable revascularization can be achieved by either PCI or coronary artery bypass surgery (CABG), or (2) to one of the nested registries for CABG-ineligible patients (PCI registry) or for PCI-ineligible patients (CABG registry). Randomized patients will be stratified based on LM disease and diabetes by site. The primary end point for the randomized comparison is noninferiority of major adverse cardiac and cerebral events between the 2 groups at 1 year. To adequately project the expected enrollment rate per site, a run-in phase was mandated for each site interested in participating in the trial. Both cardiothoracic and interventional cardiology departments within the same institution were asked to complete a questionnaire regarding their frequency of treatment of LM and 3VD over a retrospective 3-month period.

IMPLICATIONS

By replacing most traditional inclusion and exclusion criteria with the real-world decision between the cardiothoracic surgeon and the interventionalist, this study will define the roles of CABG and PCI using drug-eluting stents in the contemporary management of LM and 3VD. Results of the run-in phase were used by the steering committee to determine eligibility and to project enrollment for each site.

Drug-Eluting Stents for Interventional Revascularization of Coronary Multivessel Disease

The treatment of coronary artery disease has changed over the past 35 years since the introduction of coronary artery bypass surgery in 1968. Percutaneous coronary intervention, introduced in 1977 with balloon angioplasty, was accelerated by the establishment of elective stent placement in 1994, together with the development of suitable antiplatelet regimes. In 2002, DES were made commercially available, following the results of clinical trials in single lesions. A meta-analysis of four randomized clinical trials comparing bare stents to bypass surgery for multivessel disease conducted in the 1990s demonstrate no mortality difference at 1 year. Similar 5-year outcomes have been reported by the ARTS trial. These trials, however, showed that repeat revascularization was much higher in the stent arm, due to restenosis. Various single center (RESEARCH, T-SEARCH) and multicenter (ARTS II) registries have consistently showed a low need for repeat intervention in patients with multivessel disease with the use of DES. Three major trials comparing DES against bypass surgery are ongoing or about to start and will determine the optimum revascularization therapy in multivessel disease. The recently commenced SYNTAX randomized trial will enroll only three-vessel or left main disease, while the upcoming FREEDOM and ongoing CARDia trial will specifically enroll diabetic patients only with multivessel disease. Results for these trials are expected in 2006-2007 at the earliest.

Prolonged intubation rates after coronary artery bypass surgery and ICU risk stratification score

OBJECTIVE

To determine prolonged intubation rates among patients undergoing coronary artery bypass graft (CABG) surgery, and to evaluate the ability of the Intensive Care Unit Risk Stratification Score (ICURSS) model to predict these events.

DESIGN

Prospective observational study.

SETTING

A 24-bed ICU in a tertiary referral university hospital.

PATIENTS

Five hundred sixty-nine patients undergoing CABG surgery.

INTERVENTIONS

Variables of the ICURSS model were recorded at ICU admission. Extubation was performed according to a standard protocol. Patients remaining intubated within 8 h after ICU admission were designated as having early extubation failure (EEF). The next evaluations at 16, 24, 48, 72, and 96 h designated patients as having a prolonged intubation period (PIP) and prolonged mechanical ventilation (PMV) for 24, 48, 72, and 96 h. The ability of the ICURSS model to predict extubation failure at different cutoff values was measured using the Hosmer-Lemeshow goodness-of-fit test and the area under the receiver operating characteristic curve.

MEASUREMENTS AND RESULTS

Prolonged intubation rates were as follows: EEF, 40.2%; PIP, 17.2%; PMV for 24 h, 10.4%; PMV for 48 h, 7.6%; PMV for 72 h, 6.5%; and PMV for 96 h, 6.0%. At every cutoff, the ICURSS showed poor discrimination to predict the failure to be extubated. Calibration was also poor, although some ability to predict both EEF and PMV at > or = 48 h was shown.

CONCLUSIONS

Prolonged intubation rates after undergoing CABG surgery in our setting were comparable with those of other reports from institutions where fast-track cardiac anesthesia is currently in practice. In our cohort, the ICURSS was not useful for the prediction of length of intubation.

Gastrointestinal complications in patients undergoing heart operation: an analysis of 8709 consecutive cardiac surgical patients

INTRODUCTION

Gastrointestinal (GI) complications following heart operation may be life-threatening. Systematic analysis of risk factors to allow early identification of patients at risk for GI complication may lead to the development of strategies to mitigate this complication as well as to optimize management after its occurrence.

METHODS

Of 8709 consecutive patients undergoing heart operation during 7 years (1997-2003), 46 (0.53%) developed GI complications requiring surgical consultation. Preoperative, intraoperative, and postoperative predictors of complication and death were identified and compared with a control group.

RESULTS

Significant (P < 0.05) preoperative predictors of complication were prior cerebrovascular accident (CVA), chronic obstructive pulmonary disease (COPD), type II heparin-induced thrombocytopenia, atrial fibrillation, prior myocardial infarction, renal insufficiency, hypertension, and need for intra-aortic balloon counter-pulsation. The most frequent serious GI complication was mesenteric ischemia, which developed in 31 (67%) patients. Twenty-two (71%) of these patients were explored, and 14 (64%) died within 2 days of heart operation. Of the 9 patients with mesenteric ischemia who were not explored, 7 (78%) died within 3 days of heart operation. Other complications included diverticulitis (5), pancreatitis (4), peptic ulcer disease (4), and cholecystitis (2). The mortality rate in this group of other diagnoses was lower (40%), and death occurred later (32 days) after heart operation (P = 0.03 compared with mesenteric ischemia). Predictors of death from GI complication included New York Heart Association (NYHA) class III and IV heart failure, smoking, chronic obstructive pulmonary disease, history of syncope, aspartate aminotransferase (AST) >600 U/L, direct bilirubin >2.4 mg/dL, pH < 7.30, and the need for >2 pressors.

CONCLUSIONS

The most common catastrophic GI complication after cardiac surgery is mesenteric ischemia, which is frequently fatal. This complication may be a result of atheroembolization, heparin-induced thrombocytopenia, or hypoperfusion. Techniques to reduce the occurrence of and/or preemptively diagnosis postcardiotomy mesenteric ischemia are necessary to decrease its associated mortality.

Rapid recovery following cardiac surgery: a nursing perspective

Fast track or rapid-recovery pathways following cardiac surgery are becoming common practice in many cardiac units in order to maximize use of scarce critical care resources. Within the UK, rapid recovery generally describes same-day discharge from the initial intensive care facility to a lower-dependency unit. There are no nationally agreed protocols to help guide this practice. In a London teaching hospital a nurse-led audit was undertaken to identify which patients were selected for rapid recovery and to evaluate safety (length of hospital stay and incidences of postoperative complications) compared to a conventional recovery pathway. The study also sought to gain insight into the patients' views on rapid recovery. Data were collected on 104 patients, all patients (n = 56) who followed a rapid-recovery pathway were included. A comparison group (n = 48) was selected from patients who followed a conventional recovery but who were eligible for rapid recovery. The primary outcome, median length of hospital stay was 6 days for both groups, but the rapid-recovery group experienced significantly fewer postoperative complications. Rapid recovery as currently practised on this unit is safe for carefully selected cardiac surgical patients but barriers to rapid recovery need to be explored.